A call to create integrated services to better address the needs of migrants who use drugs in Europe

Each year, thousands of migrants enter the EU. Data on drug use in migrant populations are scarce and inconclusive. However, several risk factors make them particularly vulnerable to engaging in problematic drug use. In this perspective, we summarize the limited information that is available on migrants who use drugs and make a case as to why it is essential to improve access to health and social services, including harm reduction services, for this population. With this aim, we call for the co-creation of integrated services that better address the needs of migrants who use drugs in Europe.


Background
Migration is now a common reality for tens of millions of people around the world.Among people who have left their country of origin to settle in another country, some portion will engage in problematic drug use [1], whether initiating in their country of origin or in the host country.Data on drug use in migrant populations are scarce and inconclusive.For example, a review identified eight studies comparing drug use in first-generation migrants to drug use in the general population of which two found higher levels in migrants, four found lower levels in migrants and two found different results depending on the type of drugs [2].However, these studies were highly heterogeneous in their methodologies and the type of populations and drugs they included.Although, generally, migrant groups seem to have lower rates of substance use than host populations, several risk factors make them particularly vulnerable to engaging in problematic drug use [3].Persons who migrated often face challenges in the country they settled in, including limited job opportunities and acculturation difficulties driven, in part, through poverty (as they tend to occupy lower socio-economic positions in society), language barriers, mental health problems, and the consequences of trauma [4][5][6].The latter can stem from pre-migration traumatic experiences related to political conflict, war, or economic deprivation that prompted their migration, as well as the potentially traumatic migration journey itself [7][8][9].
Although exact numbers on the burden of drug use among migrants are inconclusive, recent global events have likely impacted the number of migrants using drugs in the European Union (EU).As a result of the war with Russia, millions of people from Ukraine, one of the countries with the highest levels of injecting drug use globally, have been entering the EU [10].In addition, globally, migrants' and refugees' self-reported use of alcohol and drugs increased by 20% during the COVID-19 pandemic [11].In March 2023, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) recognized migration as a "megatrend"-a long-term driving force that will likely have significant future influence-in its work addressing the increasingly complex and dynamic drug markets in Europe through 2030 [12].However, the EMCDDA European drug report 2023 only made a limited mention of drug use among migrants [13].In summary, migrants with problematic drug use are a neglected group and should be provided with adequate support.

Limited access to services for migrants who use drugs
Providing adequate health and social services to migrants who use drugs (MWUD) is not only a matter of human dignity and sound public health, but also of their rights under European and international law [14].However, MWUD face significant barriers when trying to access health and social services, including in European health systems.These barriers are often rooted in a range of factors, including cultural differences such as language and (mis)understanding of the health system [15], legal status [15,16], and discrimination [16,17].By denying migrants access to health and social services, irrespective of drug use, these fundamental rights are violated and perpetuate inequity, stigma, and discrimination in addition to contributing to poorer health outcomes.

Public health benefits of improved healthcare for migrant who use drugs
Improving access to health and social services, including harm reduction services, for migrants who use drugs is crucial for promoting public health.MWUD may be at a higher risk of infectious diseases, such as HIV and viral hepatitis, due to unsafe drug use practices [18][19][20], poor living conditions and, in some cases, higher prevalence of these diseases in their country of origin.For example, in 2022, the prevalence of HIV in the EU increased, which has been largely attributed to refugees living with HIV that arrived from Ukraine [21].By providing MWUD with access to harm reduction services, such as needle and syringe programs, opioid substitution therapy, and HIV and viral hepatitis B and C testing and treatment, the spread of infectious diseases will likely be reduced.Further, investment in harm reduction services is costeffective in the promotion of public health [17,22,23].

Recommendations from civil society experts on improving health and social services
MWUD may experience social marginalization or isolation due to their drug use and/or their migrant status [24].This can result in stigma, discrimination, and exclusion from social, economic, and political opportunities.Further, unaddressed health and social needs may lead to the development or exacerbation of serious mental health conditions.Inclusive practices for treating vulnerable and marginalized groups can help improve the social and mental health of MWUD [25].For example, including interpreters or cultural mediators in healthcare services improves the quality of care for patients [26,27].Civil society and health experts working with migrants who use drugs in the European Union recently published recommendations in four areas as part of an EU-funded project "Services for vulnerable migrants who use drugs in the EU (SEMID-EU)" [18] (Table 1).

Including the voices of migrants who use drugs
The civil society and health experts agreed that addiction services available in EU countries are often not sensitive to the specific needs of migrants [18].Further, a literature search conducted in 2022 revealed no published studies on the self-reported needs of MWUD [2].One study from Norway, later published in 2023, interviewed MWUD about their drug use and help seeking barriers; however, this study only included six participants [28].Despite the recommendations of many international organizations to involve people who use drugs in research and program Table 1 Areas of recommendations by civil society and health experts working with migrants who use drugs in the European Union 1. Increasing data availability and quality, to inform guidelines; 2. Increasing the availability of drug dependency services for migrants, including screening for mental health issues and involving migrants who use drugs in the development of services; 3. Eliminating country, and service level barriers for accessing these services, as well as providing migrants who use drugs with suitable information and combating stigma and discrimination; and 4. The need for increased collaboration among and within EU countries regarding healthcare for migrants who use drugs, on policy level as well as service level, including civil society organizations, peer navigation and multilingual cultural mediators." and policy development, implementation of these efforts continues to stall [29].Evidence shows that migrant involvement has a positive impact on research, service adaptations, policy dialogues, and the social and personal circumstances of migrants when they are involved [30].To this end, the SEMID-EU project team conducted a community-based participatory research to identify and explore the specific needs of MWUD in the EU aiming to improve availability of and access to services for this population.A report including the findings from 98 interviews with MWUD with 45 different nationalities living in Amsterdam, Athens, Berlin, or Paris provided a nuanced overview of the interrelatedness between problems these populations are facing related to their migration background, drug use, and additional factors such as homelessness.In addition, it described barriers and good practices for accessing healthcare and harm reduction services, including the differences between settings and different migrant populations [31].

Call to co-create integrated services that better address the needs of MWUD
Improving availability of and access to health and social services for all MWUD is essential for upholding human rights, promoting public health, and facilitating social integration and is especially urgent with the current number of migrants in the EU from Ukraine.Considering that the societal vulnerability of many migrants who use drugs leads to issues on multiple life domains, such as (mental) health problems, housing, and financial issues, an integrated, holistic approach is needed that offers support across these domains.To achieve these goals, policymakers must recognize the importance of providing MWUD with access to adequate services and work to eliminate the barriers that prevent them from accessing the care they need, while engaging migrants who use drugs at every step of the process.